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Homeowner's Quote Form

Name:
Address:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail:
Best time to contact you:
Home Description:  
Construction: Frame Brick Other:
Year Built:
Please give the date the following items were updated if the home is over 20 years old:  
Plumbing:
Heating:
Electrical:
Roof:
Heating Type:
Central Heating: Yes No
Is your home within 3 miles of a Fire Station? Yes No
Is your home within 500 feet of a Fire Hydrant? Yes No
Do you have a smoke detector? Yes No
Do you have a sprinkler system? Yes No
Do you have any deadbolts? Yes No
Do you have a central station alarm? Yes No
Do you have replacement cost coverage on your contents? Yes No
Are you a non-smoker? Yes No
If you own autos, would you be interested in combining the autos with the home owners policy for additional discounts? Yes No
Coverage Limits :
Value of Dwelling $
Liability Limit $:
Deductible $:
List any items which you desire to have scheduled for an agreed amount.(furs,jewelry,...)
General Information:  
Have you had any losses in the last three years? Yes No
If Yes:  
Date:
Type of Loss:
Description of Loss:
Amount:
Do you own a swimming pool? Yes No
If yes, is the pool completely fenced in? Yes No
Current policy expiration date:
Any Additional Comments:
Quotes maybe subject to additional underwriting information.
502 Court St. Suite 205 | Utica, NY 13502 | Phone: 315.734.9386 | Fax: 315.734.9535